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Non-Suppressive at 6 Months
Nov 22, 2002

I have been poz for 8 years and only just started meds 6 months ago due to sudden increase in VL (maintained VL <5,000 and T4>700 for first 6 years). Baseline counts when starting meds was VL: >75,000 and T4:320. Regimen is Combivir + Sustiva. Very well-tolerated so far. At 1 month, VL=1200 and T4=475. At 3-month, VL=140 and T4=435. Now at 6-month, VL=140 and T4=532. I was very encouraged at the 1 and 3 month numbers, but expected to achieve undetectable at 6 months (I have read that this is the goal of therapy and if not achieved, therapy change should be considered). My doc tells me not to worry and to come back in 3-4 months for normal monitoring, but I wonder if I should ask for resistance testing or consider therapy intensification (add viread?) Do you think it's likely for resistance to begin so quickly? I have never missed a dose, but am frequently (2 times a week) up to 2 hours late with the Combivir. I really don't want to take the chance of allowing resistance to develop if I should do something about this now while VL is low. What actions do you recommend? And is the fact that I do not take my Combivir exactly 12 hours apart (anywhere from 10-14 hours apart on some days) a possible factor in resistance? Thanks!

Response from Dr. Little

I am not inclined to think that taking your combivir 1-2 hours late is the cause for your incomplete viral suppression. I do share your concern - since yes, we do generally expect someone without resistance to have a viral load of less than 50 after 24 weeks if they have been compliant with their medications. First - I would address any possible drug-drug interactions (i.e. are you on any other - perhaps non HIV - drugs which might be lowering the levels of sustiva in your blood stream). Second, perhaps you were right on the cusp of complete suppression and at 25 weeks your viral load was less than 50 - I would repeat another viral load at 6.5 months or so to check. If you were still not fully suppressed, then yes, I would consider intensification - tenofovir is a good choice. I would not generally feel comfortable waiting another 3-4 months for the next viral load measure - the consequences are too great if you are developing resistance and miss the early detection opportunity. Finally - it is unlikely that in either of the last situations a resistance test would be successful - your viral load is too low to perform the test in most labs (i.e. at least 500-1,000 copies generally needed). So - I would talk to your provider again about these options and explain your concerns - while everything may work out quite well - this is a time to follow a bit more closely I believe.

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